KNOW ALL MEN by these presents that I, [name], a resident of [county, state], desiring to execute a Power of Attorney for medical care matters, hereby appoint [name] as my Attorney-in-Fact for me and in my name and place, for my use and benefit, to exercise the powers set out in this Power of Attorney as fully and effectually as I could do if competent, personally present, and acting.
MY ATTORNEY-IN-FACT shall have the following powers with respect to my personal care and medical treatment:
1. Decisions Respecting Medical Treatment.
a. (i) To make any and all decisions respecting my medical treatment, including power to determine when and what treatment or treatments are to be provided and that any treatment or treatments are not to be provided (including that treatments being provided are to be continued or discontinued) when, in my Attorney-in-Fact's judgment, such treatment or treatments are not in my best interest, or pursuant to my wishes as expressed in my Health Care Declaration attached hereto [omitted]. (ii) As medical treatment is defined in a subsequent paragraph, this grant of authority includes, but is not limited to, full power acting on my behalf to determine whether maintenance of respiration, by means of a ventilator or otherwise, and alimentation and hydration by means of physical or surgical intubation, intravenous injection, or otherwise are to be undertaken or, once undertaken, continued or discontinued.
b. To authorize or to decline to authorize my admission to a medical, nursing, residential, or similar facility and to enter into agreements on my behalf for my care.
c. To exercise full power acting on my behalf to authorize or to decline any treatment with respect to which I could if competent take such action when, in my Attorney-in-Fact's judgment, a contrary course would not be in my best interest, taking into account my medical condition at the time, the prognosis for recovery, my wishes as previously expressed to my Attorney-in-Fact, and in my Health Care Declaration, and all other factors that my Attorney-in-Fact deems appropriate.
2. Consents and Waivers. To sign any and all consents required for the provision of medical treatment, and to sign any and all waivers of liability on my behalf to the extent reasonably required by providers to secure their good faith compliance with a decision not to initiate or, once begun, to discontinue any medical treatment.
3. Obtain Information. To request, obtain, receive, and inspect any and all information bearing upon my health and relevant to any determinations to be made respecting my medical treatment, to sign whatever authorizations for release of information may be required by providers or others, and to waive any rights I may have for breach of confidentiality of medical records for release of such information to my Attorney-in-Fact.
4. Legal Action. To retain counsel and to take any and all legal actions on my behalf and in my name, or otherwise as my Attorney-in-Fact deems appropriate, that may be necessary or appropriate to obtain compliance with my wishes as expressed elsewhere or as determined by my Attorney-in-Fact pursuant to this Power of Attorney, including but not limited to action to secure appointment of a conservator, guardian, or committee, to obtain a declaratory judgment, and to seek injunctive relief and damage (actual, exemplary, or punitive).
5. Perform All Acts Necessary. To do and perform all and every act and thing whatsoever required, necessary or appropriate with respect to my medical care and treatment, in exercise or effectuation of the powers granted under this Power of Attorney, to be done as fully to all intents and purposes as I might or could do if personally present.
6. When Powers Shall Be Exercised. To determine in my Attorney-in-Fact's discretion the time when, purpose for, and manner in which any power granted to my Attorney-in-Fact by this Power of Attorney shall be exercised, and the conditions to be accepted or waivers to be granted incident thereto.
7. Durable Power. This Power of Attorney shall not be affected by my disability, and all acts done pursuant to its terms shall be as fully effective as if I were competent and were myself so acting or causing others to act. This declaration of durability is made pursuant to the laws of [state] but if for any reason said laws do not apply, then pursuant to any other law of [state] or any other jurisdiction that does apply and that now or may hereafter authorize powers of attorney that survive the incompetence of the principal.
8. Good Faith Reliance. A health care provider who relies in good faith on a consent or waiver given under this Power of Attorney shall be relieved of any and all liability.
9. Provisions Severable. If for any reason any provision of this Power of Attorney is determined not to be legally binding in any regard, I ask that it be deemed separable and that all other provisions be deemed binding to the greatest extent possible, and that each provision nonetheless be honored to the fullest extent possible by my Attorney-in-Fact, attorney, physicians, and others who may provide medical treatment or be involved in decisions respecting my care, as the expression of my will.
10. Definition of "Medical Treatment." As used in this Power of Attorney, the term "medical treatment" means interventions by doctors, nurses, paramedical, or any other health care provider (including a health care facility) in the care of my body and mind, including all medical and surgical procedures, mechanical or otherwise, treatments, therapies, including drugs and hormones, which may substitute for, replace, supplant, enhance, or assist any bodily function. This specifically includes maintenance of respiration, alimentation or hydration by any type of artificial means whatsoever, and with respect to all medical treatments, it includes existing technology as well as any methods or techniques that may be hereafter developed and perfected.
IF FOR ANY REASON my Attorney-in-Fact refuses or is unwilling or unable to act pursuant to this Power of Attorney, I hereby appoint [name] as my Attorney-in-Fact, TO ACT, for me and in my name and place, for my use and benefit, to exercise the powers set out above in this Power of Attorney as fully and effectually as I could do if competent, personally present, and acting. A person asked to comply with an order or decision of said successor Attorney-in-Fact may request that said successor provide a certification, in writing, that my Attorney-in-Fact has refused or is unwilling to act hereunder or a certification from a physician that my Attorney-in-Fact is unable, for medical reasons, to act pursuant to this Power of Attorney or, if my Attorney-in-Fact's inability to act is by reason of death, an appropriate death certificate, but no other proof of authority shall be required, and any person who relies upon my successor Attorney-in-Fact's representation to them that said successor is acting pursuant to this Power of Attorney because of my Attorney-in-Fact's inability to act shall not be liable to me or my estate for complying with such request.
I HEREBY RATIFY ALL that my Attorney-in-Fact shall do or cause to be done by virtue of this Power of Attorney, and hold harmless my Attorney-in-Fact for any action taken in good faith pursuant to this Power of Attorney. I hereby authorize and direct whoever shall be responsible for my estate or have power over any property of mine to reimburse my Attorney-in-Fact for any costs (including legal fees) reasonably incurred in or as a result of acting pursuant to this Power of Attorney.
IN WITNESS WHEREOF, I have hereunto set my hand seal this [date].